The role of economic evidence in Canadian oncology reimbursement decision-making: To lambda and beyond

Objective: The overarching question addressed in this article is: what has been the impact of economic evidence to Canadian drug reimbursement decisions; within this, has an (explicit or implicit) threshold been identified for making such decisions; and is the impact or threshold different for oncology medications? Methods: Three sequential strategies were employed: a literature search, a review of publicly available Canadian reimbursement recommendations, and a one-day key informant roundtable, held with a purposive sample of 13 individuals from across Canada to gain information not readily accessible from the public domain. Results: Despite the formal requirement for structured economic evidence, the limited public information suggests that its uptake in the Canadian decision-making process has been tentative. Implicit economic thresholds have been published in Australia and the United Kingdom, but not in Canada. Based on reviews of reimbursement recommendations, thresholds specific to oncology medications may be higher than for nononcology medications, in Canada and elsewhere. Canadian reimbursement recommendations can appear inconsistent with respect to clinical evidence, economic evidence, and nonevidentiary factors, possibly because of a lack of transparency or context-sensitive interpretations. The key informant roundtable provided reasons for the inconsistent uptake of economic evidence: panelists were divided between those who found economic information useful and supportive to decision-making, and those who did not. Panelists generally agreed on the need for publicly defensible and ethical reimbursement restrictions. They suggested the following improvements: transparency of processes and decisions, dynamic formularies that can adapt with evolving treatment practices and clinical data, broader representation of expertise on review panels, greater use of ethics to resolve conflicts arising from different perspectives, and the development of an explicit Canadian weighting system for evidence and values. Conclusions: Economic evidence has been tentatively incorporated in reimbursement decision-making in Canada. Public reasons for recommendation indicate that this evidence is used primarily with respect to the attractiveness of an incremental cost-effectiveness ratio. Oncology drugs seem to be adopted at the highest thresholds of acceptability. Yet, decision-makers expressed a need to move beyond lambda, rejecting the simplicity of the incremental cost-effectiveness ratio and considering alternative strategies to improve decision-making, including formal guidance for weighting both evidence and values.